Psychobiologic disorders

Andrew SolomonDepression, The Secret We Share

Watch a Videohttp://www.ted.com/talks/andrew_solomon_depression_the_secret_we_share.html

Video LinkPsychobiologic DisordersPart OnePVN 123Mental Health Nursing

ObjectivesIdentify common subjective and objective evidence associated with common mental health disordersAnxiety DisordersDepressionBipolar DisordersSchizophreniaPersonality DisordersCognitive DisordersSubstance and other dependenciesEating Disorders

Identify nursing interventions, therapies, screening tools, that may be utilized in the safe care, management, and health promotion, for individuals who experience these disorders.

Determine desired outcomes associated with these disordersAnxiety DisordersPanic DisorderPhobiasOCDGADStress Related Disorders(Acute Stress Disorder & PTSD)AnxietyAnxietyResponse to stressHigh levels result in behavior changesTends to be persistent (often disabling)

Levels of anxietyMild (restless/irritable/increased motivation)Moderate (agitated/muscles tighten)Severe (unable to function / ritualistic behaviors / unresponsive)Panic (distorted perception / hallucinations / loss of rational thought / immobility)Anxiety DisordersPanic DisorderRecurrent panic attacks

PhobiasUnreasonable fear of objects or situations

Obsessive-Compulsive Disorder (OCD)Unrealistic obsessions (thoughts)Compensated for with compulsive behaviorsEx: repeatedly cleaning an object or constant hand washing

Generalized Anxiety Disorder (GAD)Excessive worry (more than 6 months)

Stress-related DisordersAcute Stress DisorderAfter exposure to traumatic eventCauses numbing, detachment, amnesia about the event (no more than 4 weeks)

Posttraumatic Stress Disorder (PTSD)Caused by a traumatic eventFear, horror, flashbacks, detachment, foreboding, restricted affectImpairment lasts longer than one month and can last for years

Coping and Defense Mechanisms Anxiety Disorders:DisplacementUndoing, reaction formationIntellectualizationIsolationRepression

*** If you dont remember these from last class look them up!!!

Risk Factors Anxiety Disorders:Much more likely in women (except OCD)Precipitated by exposure to traumatic event or experienceExperiencing smells or sounds associated with the eventCan trigger panic attackCan be due to acute medical conditionAlways rule out a physical causeCan be related to current use or withdrawal from a chemical substance (ex: alcohol)

Subject/Objective DataPanic DisorderPanic episodes last 15 to 30 minutes

Four or more of the following:PalpitationsSOBChoking / sense of smotheringChest painNauseaFeelings of depersonalizationFear of dying / insanityChills and hot flashesBehavior changes / persistent worries about next attackAgoraphobia (fear of being in places or situations of previous attacks)

Subjective/Objective DataPhobias:Social Phobia (fear of embarrassment)Unable to perform in front of othersDread social situationsBelieve others are judging them negativelyImpaired relationships

Agoraphobia (fear of being outside)Impaired ability to work or perform duties

Other Phobias (ex: fear of strangers, flying, the dark)Fear specific objects, experiences or situations

Subjective/Objective DataOCDRitualistic behaviorsDifficulty meeting self care needsIf performing constant hand washingSkin damageInfection

Subjective/Objective DataGADImpairment in one or more areas of functioningEx: work-related duties, self care

At least three of the following manifestationsFatigueRestlessnessTrouble concentratingIrritabilityMuscle tensionSleep disturbance

Subjective/Objective DataStress-Related Disorders

Standardized Screening ToolsAnxiety DisordersHamilton Rating Scale for Anxiety

Modified Spielberger State Anxiety Scale

(see handouts)

Nursing CareAnxiety DisordersStructured interview keep client focused

During Crisis or in Acute Anxiety:Provide safety and comfort for client and staffDo not reinforce teaching unable to problem-solveRemain with client and provide reassurance

THEN

Nursing Care (continued)Anxiety DisordersProvide Milieu TherapyStructured environmentMonitor/protect from harmDaily activities / focus on cooperation and sharingUse therapeutic communication skillsOpen ended questionsHelp client to express, validate, and acknowledge feelingsAllow client to participate in decision making

Encourage relaxation techniquesMild to moderate anxiety

Instill hope for good outcomes (no false reassurance)

Enhance self-esteemEncourage positive statementsDiscuss past achievements

Assist to identify interfering defense mechanisms

Client Education

Other Therapies Anxiety DisordersCognitive ReframingBehavioral TherapiesRelaxation TrainingModelingSystematic desensitizationFloodingResponse preventionThought stoppingEye Movement Desensitization Therapy (EMDR)Unfreezes fragments or traumaGroup/Family Therapy (PTSD)Medications Anxiety DisordersAntidepressantsZoloft, Elavil

Sedative hypnotic anxiolyticsValium

Serotonin Norepinephrine reuptake inhibitorsEffexor

Non-barbiturate anxiolyticsBuspar

Other Medications ***( used as mood stabilizers)

Beta Blockers AntihistaminesAnticonvulsants

Remeron (serotonin norepinephrine dis-inhibitor)Used to help clients rest when panic attack occurs during sleep

Client Outcomes!Anxiety DisordersWill verbalize decreased anxietyWill be rested upon awakeningWill develop realistic goals for the futureWill regularly attend support groupWill demonstrate appropriate use of relaxation techniques

Quick Quiz! (answers in your book!)OCDPanic DisorderAcute Stress DisorderAgoraphobiaSocial PhobiaPTSDTraumatic event causing symptoms for months after event takes placeAExposure to a traumatic event, resulting in numbing, detachment, and amnesia about the event for up to 4 weeksBFear of speaking with or interacting with othersCClinical findings including chest pain, palpitations, feelings of impending doomDFear of being out in open spacesERitualistic compulsions and recurrent thoughtsFQuick Quiz!A client being evaluated in her providers office tells the nurse, I remove my old makeup and apply new makeup every hour or so because I look horrible. The nurse should understand that this behavior is characteristic of which of the following disorders?

A.GADB.AgoraphobiaC.OCDD.PTSDQuick Quiz!When collecting data from a client who states that she has been dealing with constant anxiety for the past few weeks, the nurse should use which of the following communication techniques?_____Ask open ended questions_____Provide reassurance_____Discuss the clients past achievements_____Offer advice about how to reduce anxiety_____Invite the client to participate in decision makingDepressionDysthymic Disorder

Major Depressive Disorder

I Had A Black Dog http://youtu.be/XiCrniLQGYc

Watch the Video!About DepressionMood (affective) disorder

Widespread issue

Ranks high among causes of disability

Can be comorbid with:Anxiety disordersSchizophreniaSubstance abuseEating disordersPersonality disorders

Client may be at risk for suicidePersonal or family history of suicide attemptsComorbid anxiety or panic attacksComorbid substance abuse or psychosisPoor self esteemLack of social supportChronic medical conditionDepressive Disorders - MDDMajor Depressive Disorder (MDD)

Single or recurrent episodes of unipolar depressionNot associated with mood swings (unipolar)

Change in normal functioningSocial, occupational and self care deficitsPlus.At least 5 of the following occurring nearly every day (for most of the day) for a minimum of 2 weeks:Depressed moodDifficulty with or excessive sleepingIndecisivenessDecreased concentrationSuicidal ideationChanges in motor activityUnable to feel pleasureIncrease or decrease in weight ( 5% of total body weight over one month)

Dysthymic DisorderMilder and more chronic form of depressionOnset is earlyChildhood and adolescenceLasts at least 2 years (adults)1 year in childrenAt least three clinical findings of depressionMay become MDD later in lifeClinical manifestations less severe than with MDD

MDD Specific ClassificationsPsychotic FeaturesAuditory hallucinations, delusions

Atypical FeaturesChanges in appetite, wt. gain, excessive daytime sleeping

Postpartum OnsetBegins within 4 weeks of childbirthMay include delusionsMother and infant may be at high risk

Seasonal CharacteristicsSeasonal Affective Disorder (SAD)Occurs during winterCan be treated with light therapy

Chronic FeaturesEpisode lasting more than 2 years

Phases of DepressionPhaseCharacteristicsTreatmentAcuteSevere clinical findings of depressionTreatment lasts 6 12 weeksMay require hospitalizationReducing symptomsSuicide potential determinedSafety precautions implemented1:1 observationMaintenanceIncreased ability to functionTreatment4-9 monthsRelapse prevention is goal of educationMedication therapy & Psychotherapy are goals of treatmentContinuationRemission of clinical findingsMay last for yearsPrevention is goal of treatment

Depression Risk FactorsFamily history / previous personal history of depression

Twice as common among females 15 40 years

Very common among elderlyMore difficult to recognizeMay go untreatedMay look like dementiaMemory lossConfusionBehavioral problemsMay seek help for somatic symptoms

Other Risk Factors:Stressful eventsMedical illnessPostpartum femalePoor social networkComorbid substance abuse

*May be primary disorder or response to another mental or physical disorder

Subjective DataDepressionAnergia (lack of energy)Anhedonia (lack of pleasure in normal activities)AnxietySluggish (most common) or unable to relax or sit stillChange in eating patterns Usually anorexia in MDDIncreased intake with DysthymiaChange in bowel habits (usually constipation)Sleep DisturbancesDecreased interest in sexual activitySomatic complaints (fatigue, GI symptoms, pain)

Objective DataDepressionSad with blunted affectPoor grooming / lack of hygieneSlowed physical movement / slumped postureAgitation (pacing/finger tapping) can also occurLittle or no effort to interact / socially isolatedSlowed speechDecreased verbalizationDelayed responsesStandardized Screening ToolsDepressionHamilton Depression Scale

Beck Depression Inventory

Geriatric Depression Scale

Zung Self-Rating Depression Scale

Confidential Screening Toolhttp://depressionscreen.org/

See handouts!

Medications - DepressionClassification / Medication ExampleNursing ConsiderationsSelective Serotonin Reuptake Inhibitors (SSRIs)Celexa (citalopram)Prozac (Fluoxetine)Zoloft (Sertraline)Side effects includeNauseaHeadacheCNS stimulation (agitation/insomnia/anxiety)Sexual dysfunction may occurWeight gain with long term use (follow healthy diet)Tricyclic AntidepressantsElavil (Amitriptyline)Orthostatic hypotensionDizziness change positions slowlyMonoamine Oxidase Inhibitors (MAOIs)Nardil (Phenelzine)Anticholinergic effectsSugarless gumHigh-fiber foodsIncrease fluid intake (2-3L/day)Avoid foods with tyramine!Ripe avocadosFigsFermented/smoked meatsLiverDried or cured fishMost cheesesSome beer and wineProtein dietary supplements**Combinations of medication and foods can cause hypertensive crisis / deathSedative Hypnotic Anxiolytics (Benzodiazepines)Valium (Diazepam)Ativan (Lorazepam)Watch for CNS DepressionAvoid using other CNS DepressantsAvoid hazardous activitiesAvoid caffeine (interferes with effect of medication)Serotonin norepinephrine reuptake inhibitorsEffexor (Venlafaxine)Side effects include:NauseaWeight gainSexual dysfunctionNonbarbiturate AnxiolyticsBuspar (Buspirone)Therapeutic effects onset may take 2 to 4 weeksNursing CareDepressionMilieu TherapySelf-CareMonitor abilities to perform ADLsEncourage independenceEncourage participation in decision making

CommunicationRelate therapeuticallyMake time to be with clientMake observations rather than asking questionsI notice that you were at group todayGive simple concrete directionsGive client time to respond

Maintain a safe environment

Client Teaching for Anti-Depressant Medications

Do not discontinue medications suddenly

May take time for therapeutic effect1 3 weeks for initial effectUp to 2 months for maximal response

Avoid hazardous activitiesDrivingOperating heavy equipment / machinery

Serotonin SyndromeWatch the video

http://www.youtube.com/watch?v=egfXW74LMi8

Other Treatments PsychotherapyProblem solvingIncreasing coping abilitiesChanging negative thinkingIncreasing self-esteemAssertiveness trainingUsing community resources

Alternative TherapiesSt. Johns WortSide effects (photosensitivity, skin rash, rapid heart rate, GI distress, abdominal pain)Can increase or reduce levels of medications being taken Serotonin Syndrome may occur if taken with SSRIs, MAOIs, atypical antidepressants, tricyclic antidepressants.

Light TherapyFirst line treatment for SADInhibits nocturnal secretion of melatoninExpose face to 10,000-lux light box for 30 min/day

Electroconvulsive Therapy (ECT)Specially trained nurse monitors the client before and after procedureWatch for cardiovascular disease, neuromuscular disorders, complicated pregnancy prior to treatment

Transcranial Magnetic Stimulation (TMS)Electromagnets stimulate the brain

Vagus Nerve Stimulation (VNS)Implanted device stimulates vagus nerve

Electroconvulsive Therapy (ECT)Watch the video

Sherwin Nuland: How Electro-shock Therapy Changed Me

http://www.ted.com/playlists/9/all_kinds_of_minds.html

Client Education and OutcomesEducation after dischargeReview clinical manifestations with clients and familyHelps to identify relapseReinforce intended effects and side effects of medsExplain importance and benefits of adherence to therapiesEncourageRegular exercise (30 min/day 3 to 5 days/wk)Shorter intervals are helpful

OutcomesThe client will express increase in mood.The client will adhere to the medication regimen.The client will remain safe and notify provider of any thoughts of suicide.

Quick Quiz!A nurse is interviewing a 25 year-old client diagnosed with dysthymia. Which of the following findings should the nurse expect?

A.There are wide fluctuations in mood.B.There is no evidence of suicidal ideation.C.The symptoms last for at least two years.D.There is an inflated sense of self-esteem.Quick Quiz!A client is prescribed the SSRI paroxetine (Paxil), but wants to continue taking St. Johns Wort. What should the nurse tell the client and spouse about taking this medication concurrently with St. Johns Wort?Bipolar DisordersBipolar I Disorder

Bipolar II Disorder

Cyclothymia

Watch a Movie! - EXCELLENT!!"Up/Down" Bipolar Disorder Documentary FULL MOVIE (2011)

About 1 hours long

Make some popcorn and get comfy!

Put up the Big Screen

Enjoy and learn lots!!

http://www.youtube.com/watch?v=eyiZfzbgaW4

Bipolar DisordersMood disordersRecurrent episodes of depression and mania

Usually emerge in late adolescence and early adulthoodCan be diagnosed in school age childrenSide effects of medication and clinical manifestations of bipolar disorders mimic symptoms of ADHDChildren not usually diagnosed until after age 7

Periods of normal functioning alternating with illnessSome clients maintain occupational and social function

Care mimics the phase of the disease experienced

Bipolar Disorders and ComorbiditiesBipolar DisordersBipolar I DisorderAt least one episode of mania alternating with depression

Bipolar II DisorderMore than one or more hypomanic episodes alternating with MDD. Differs from Bipolar I Clients do not have manic phases

Cyclothymia2 years of repeated hypomanic episodes alternating with MINOR depressive episodes

ComorbiditiesSubstance abuseMore rapid cycling of maniaUsed for self-medicationDirect impact on onset of mental health disorderAnxiety DisordersEating DisordersADHD

Watch a VideoLaura Bain - Living with Bipolar Type II

http://www.youtube.com/watch?v=8Ki9dgG3P5M

Watch a VideoUnderstanding Bipolar Disorder

http://www.youtube.com/watch?v=CDK50WQEOJc

Phases, Characteristics and Treatment Bipolar Disorders

Bipolar BehaviorsManiaAbnormal elevated moodDescribed as expansive or irritableNormally requires inpatient treatment

HypomaniaLess severe than maniaLasts at least 4 daysAccompanied by 3 to 4 clinical findings of maniaHospitalization may not be necessaryClient is less impaired

Mixed EpisodeManic and major depression experienced simultaneouslyImpaired functioningMay require hospitalization (self harm or other violence)

Rapid CyclingFour or more episodes of mania in 1 year

Data CollectionBipolar DisordersRisk FactorsPhysical illness Substance abuse (cocaine / methamphetamine)

RelapseSubstance use (alcohol, drugs, caffeine)May lead to manic episodeSleep disturbancesBefore, associated with, or brought on by manic episode

Standardized Screening ToolMood Disorders Questionnaire (see handout)

Clinical ManifestationsBipolar DisordersManic CharacteristicsDepressive CharacteristicsPersistent elevated mood (euphoria)Agitation and irritabilityDislike of interferenceIntolerant of criticismIncreased talking and activityFlight of Ideas rapid/continuous speaking with frequent topic changesGrandiose view of self and abilitiesImpulsiveDemanding / manipulativeDistracted easilyPoor judgmentAttention-seeking behaviorImpaired social and occupational functionDecreased sleepNeglect ADLsPossible delusions / hallucinationsDenial of illnessFlat/blunted affectTearfulLack of energyAnhedonia (loss of pleasure/lack of interest)Discomfort or painDifficulty concentrating / problem solving / focusingSelf-destructive behaviorLoss or increase of appetiteLoss or increase of sleepDisturbed sleepPsychomotor retardation / agitationNursing CareBipolar DisordersBased on the phase of mania clients are experiencing

Acute PhaseFocused on safety and maintaining physical health

Therapeutic Milieu (in acute care setting)Provide safe environmentEvaluate for suicidal thoughts, escalating behaviorDecrease stimulationFollow protocols for restraints/observations/seclusion1:1 if threat of self-injury or harm to othersFrequent rest periods Provide physical outlets Short activitiesNo high level concentration or detailed instructions

Monitor and maintain self-care needsMonitor sleep / fluid intake / nutritionProvide nutritious foods to eat on the runSupervise clothing choicesGive step-by-step remindersEncourage independence

CommunicationUse calm and specific approachGive concise instructions and explanationsProvide consistency among staff membersAvoid power strugglesDont react personally to clients commentsList and act on legitimate grievancesReinforce non-manipulative behaviorsMedications (examples)Bipolar DisordersMood Stabilizers (Lithium carbonate - Eskalith)Narrow therapeutic range = potential for toxicity! (requires regular lab draws and testing)What is a safe, effective dose for one person may be toxic to another. According to the US Food and Drug Administration (FDA),in generalthe desirable level is 0.6 to 1.2 mEq/L. However, they point out, "Patients unusually sensitive to Lithium may exhibit toxic signs at serum levels below 1 mEq/L.

Antiepileptic Agents (Depakote, Klonopin, Lamictal, Neurontin, Topamax)Act as mood stabilizers

Benzodiazepine (Ativan)Short term for addressing sleep impairment related to mania

Antidepressant (Prozac)Manage MDD

Antipsychotic (Risperdal)Manage psychotic disturbances during mania

Other Treatment / Discharge Care Bipolar DisordersECTUsed to subdue extreme manic behaviorParticularly used when medications have not workedCan also be used for suicidal client or for rapid cycling*See nursing actions related to ECT in prior slide

Care after DischargeManagement of continuation and maintenance phasesRecommend case management to follow clientEncourage group, family, and individual psychotherapyImprove problem-solving and interpersonal skillsReinforce teaching regardingChronic nature of the disorderNeed for long-term pharmacological and psychological supportFactors of relapseImportance of maintaining sleep, nutrition and activity patternMedication administration and adherence to regimenOutcomes and ComplicationsBipolar DisordersOutcomesClient will refrain from self harmClient will rest 4 to 6 hours / nightClient will maintain adequate fluid and nutrition intakeClient will use appropriate communication skills to meet needsClient will participate in self-careClient will not experience relapse

ComplicationsTrue manic episode client will not stop moving, does not want to eat, drink, or sleepEpisodes can last for weeks to monthsGreater risk for psychotic episodes when manicCan become a medical emergencyNursing actions include:Prevent harm to client or othersDecrease physical activityPromote fluid and food intakeEnsure 4 6 hours of sleep / nightManage medicationQuick Quiz!

A client who has Bipolar I disorder is in the acute phase and unable to eat or sleep. The clients moods change rapidly from elated to agitated. If this client threatens to hit a staff member or another client, which of the following verbal response by the nurse is appropriate?

You will be put in seclusion and kept there if you make any more threats.Do not hit him or me. If you cannot control yourself, we will help you.Thats enough! You know we do not tolerate this type of behavior.That will only make things worse. Why would you want to hurt someone?

Quick Quiz!A client who has Bipolar I Disorder is standing with a group of clients in the mental health unit. The client is talking excitedly and at great length about a variety of topics. The nurse can see that the other clients are becoming anxious and restless, but do not know what to do to stop the conversation. Which of the following is the first action the nurse should take?

Give honest feedbackAdminister a sedativeSet limitsUse distraction

Schizophrenia and Psychotic DisordersParanoidDisorganizedCatatonicResidualUndifferentiated

SchizophreniaGroup of psychotic disordersAffect thinking, behavior, emotions, and ability to perceive reality

May result from combination of genetic and non-genetic factors Brain injury at birthNutritional factorsViral infectionHormonal imbalances

Typical onset in late teens/ early 20sHas occurred in young childrenDiagnosis should not be made for children < 7 yearsRule out ADHD with violent tendenciesMay begin later in adulthood

Becomes problematic when clinical manifestations interfere with relationships, self-care, ability to work

Categories / Taxonomies SchizophreniaType of SchizophreniaCommon SymptomsParanoidCharacterized by suspicion toward othersHallucinations (auditory hearing voices)Delusions (false/fixed beliefs)Other directed violence may occurDisorganizedCharacterized by Withdrawal from societyVery inappropriate behaviors (poor hygiene / mutter to self)Frequently seen in homeless populationLoose associationsBizarre mannerismsIncoherent speechHallucinations and delusionsLess organized than in paranoiaCatatonicCharacterized by abnormal motor movementsStages WithdrawnExcitedWithdrawn StagePsychomotor retardation may appear comatoseWaxy flexibilityOften have extreme self-care needsTube feeding unable to eatExcited StageConstant movement / unusual posturing/ incoherent speechSelf-care needs may predominateMay be danger to self or othersResidualActive clinical manifestations no longer presentTwo or more residual findingsAnergia/ Anhedonia / AvolitionWithdrawal from social activitiesImpaired role functionSpeech problems (Alogia)Odd behaviors (strange walking)UndifferentiatedClinical manifestations of schizophrenia but do not meet criteria for any other typesAny positive or negative symptoms may be presentOther Psychotic DisordersSchizoaffective DisorderCriteria for Schizophrenia plus one of the affective disordersDepression / mania / mixed disorderClient often in acute phase of Bipolar I with psychosis characteristics

Brief Psychotic DisorderClinical manifestations last between 1 day and 1 month

Schizophreniform DisorderClinical manifestations of SchizophreniaDuration 1 to 6 monthsSocial dysfunction may or may not be presentSometimes Dx used until further evaluation can be made

Shared Psychotic DisorderOne person begins to share beliefs of another with psychosis. Also called folie a`deux

Secondary (induced) PsychosisBrought on by medical disorder (Ex: Alzheimers)Can be caused by use of chemical substancesWatch a VideoWhat It's Like to Hear Voices (Schizophrenia) use headphones for best experience

http://www.youtube.com/watch?v=0vvU-Ajwbok

Watch a VideoI Hear Voices - A Story on Schizophrenia

http://www.youtube.com/watch?v=KBRAC4acr70

Characteristics and Behaviors SchizophreniaCharacteristicsExamples of BehaviorsPositive SymptomsEasily identified clinical manifestationsHallucinationsDelusionsSpeech alterationsBizarre behavior (ex: walking backward constantly)Negative SymptomsManifestations more difficult to treat than positive symptomsAffect (blunted)Algoia (may only respond vaguely or mumble)Avolition (lack of motivation)Can complete a task and unable to start the next one without promptingAnhedonia (lack of pleasure or joy)Anergia (lack of energy)Cognitive SymptomsProblems thinkingMakes independent living difficultDisordered thinkingUnable to make decisionsPoor problem-solvingDifficulty concentratingMemory deficitsDepressive SymptomsHopelessnessHelplessnessSuicidal IdeationTypes of DelusionsDelusionsExamplesIdeas of ReferenceMisconstrue trivial eventsAttach personal significance to eventsBelieving others are talking about themPersecutionFeeling singled out for ham by othersGrandeurBelieve they are all powerful and importantSomatic DelusionsBelieve that body is changing in unusual wayGrowing a third armJealousyFeel spouse is involved with someone elseBeing ControlledBelieve outside forces control themThought BroadcastingBelieve their thoughts are heard by othersThought WithdrawalBelieve thoughts have been removed from their mind by someone/something elseReligiosityObsessed with religious beliefs

Examples of Alterations in Speech, Perception, BehaviorSchizophreniaFlight of ideasAssociative loosenessMay say sentence after sentenceSentences may relate to several topicsListener is unable to followNeologismsMade up wordsWords only have meaning to the clientEx: I trangled and flittedEcholaliaRepeating words spoken to themClang AssociationMeaningless rhyming words (often forceful)Ex: Oh fox, box, and loxWord SaladWords jumbled togetherLittle meaning or significanceEx: Hip hooray, the flip is cast and wide-sprinting in the forestAlterations in SpeechAlterations in Perception

HallucinationsAuditory (hearing things)Visual (seeing things)Olfactory (smelling odors)Gustatory (tasting things)Tactile (feeling sensations)

Alterations in Behavior

Extreme agitationStereotyped BehaviorsAutomatic ObedienceWavy FlexibilityStuporNegativismEchopraxia (imitates movements of others)Personal Boundary Difficulties

Depersonalization feeling of losing identityDerealization feeling the environment has changesScreening ToolsSchizophreniaGlobal Assessment of Function (GAF) ScaleHelps determine ability to perform ADLs and function independently

Scale for Assessment of Negative Symptoms (SANS)

Simpson Neurological Rating Scale

*** See Handouts!Nursing CareSchizophreniaUse Milieu Therapy

Promote therapeutic communication

Establish trusting relationship

Encourage development of social skills and friendships

Encourage participation in group work and psychotherapy

Determine discharge needs

Relate wellness to symptom management

Collaborate with clientSymptom management techniques

Encourage medication compliance

Reinforce teaching regarding medications

Communication

Ask client directly about hallucinations and delusionsDont argue or agreeMay say: I dont hear anything, but you seem frightened (hallucination)May say: I cant imagine that the President would have a reason to kill a citizen, but it must be frightening for you to believe that (delusion)Provide safetyFocus on reality based subjectsIdentify symptom triggersBe genuine and empathetic

Internet Moment Search this!

Extrapyramidal Side Effects

What did you find?Write it down and bring it to class for discussion

MedicationsSchizophrenia

Care after Discharge and Client OutcomesSchizophreniaAfter DischargeClient OutcomesRecommend case manager to follow

Encourage group, family, and individual psychotherapyImprove problem-solving / interpersonal skills

Reinforce teachingNeed for self care to prevent relapseMedicationEffectsSide effectsCompliance

Importance and resources for support groups

Drug and alcohol abstinence

JournalingMonitor effectiveness of medsJournal feelings and changes in behaviorClient will regularly attend support groups

Client will maintain an appropriate level of self-care

Client will maintain medication adherenceQuick Quiz!Positive symptoms of Schizophrenia include which of the following?_____Auditory hallucinations_____Lack of motivation_____Minimal to no energy_____Delusions of persecution_____Motor agitation_____Flat affectQuick Quiz - MatchingAnswerSchizophreniform DisorderAPsychotic symptoms caused by abuse of chemical substances or physical illnessSchizoaffective DisorderBAn absence of active symptoms of schizophrenia with two or more persistent or lingering symptomsShared Psychotic DisorderCPsychotic behavior lasting between 1 and 6 months that may not impair the clients ability to function at work or in social situationsResidual SchizophreniaDSymptoms of schizophrenia along with symptoms of mania or major depressionInduced PsychosisE One person sharing the delusional beliefs of a person who has psychosisContinue to Part 2Psychobiological DisordersPhaseCharacteristicsTreatment

Acute

Acute Mania Treatment generally 6 to 12 weeks Hospitalization required Reduction of mania symptoms is goal of treatment Risk of harm to self or others determined 1:1 Supervision

Maintenance

Increased ability to function Treatment usually 4 to 9 months Relapse prevention through education, medication, therapy, and psychotherapy are goals of treatment

Continuation

Remission of symptoms Treatment usually continues throughout the clients lifetime Prevention of future manic episodes is goal of treatment

Medication UseExamplesTeaching

Atypical Antipsychotics Current medications of choice Generally treat both positive and negative symptoms Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Clozapine (Clozaril) Weight gain follow healthy diet / exercise Monitor weight gain Agitation / dizziness / sedation / sleep disturbance Educate client to report these to physician Med may need changed

Conventional Antipsychotics Used for mainly positive psychotic symptoms Haloperidol (Haldol) Loxapine (Loxitane) Chlorpromazine (Thorazine) Fluphenazine (Prolixin) Anticholinergic effects Chew sugarless gum Eat high fiber foods 2 3 L of fluids/day Instruct about clinical findings and actions regarding postural hypotension Getting up slowly from lying or sitting Monitor for extrapyramidal side effects

Antidepressants Used temporarily to treat depression Common in Schizophrenia Paroxetine (Paxil) Monitor for suicidal ideation Particularly in beginning dosages Increased thoughts of self-harm Observe for deepening depression Notify MD Instruct not to abruptly stop taking medication To avoid withdrawal symptoms

Anxiolytics / Benzodiazepines Used to treat anxiety (often found in Schizophrenia) Also for treating positive and negative symptoms of Schizophrenia Lorazepam (Ativan) Clonazepam (Klonopin) Instruct about sedative effects Need for blood tests Monitor for agranulocytosis Low WBCs THESE MEDS ARE USED WITH CAUTION IN OLDER ADULTS!!!